Sedation Billing + Note

A tool to help with your Emergency Department OHIP procedural sedation billing & documentation. Version 0.1

Billing Info

Procedure Skin with GA: Abscess/haematoma - sc - one Z102 Perianal abscess Z105 Ischiorectal abscess Z107 FB removal Z115 Bartholin's I+D Z715 IM abscess/hematoma Suture: Suture < 5 cm Z176 Suture 5-10 cm Z175 Suture 10.1-15 cm Z179 Suture > 15 cm Z176 Suture face/bleeder/layer < 5 cm Z177 Suture face/bleeder/layer < 5-10 cm Z190 Suture face/bleeder/layer < 5-10 cm Z192 Earlobe lac R024 Repair muscle and skin R525 Zone 1 repair of digit Z189 Complicated lac of face x 20mins Z187 Complicated lac, not face x 20mins Z188 Excision of FB R518 Chest: Chest tube insertion Z341 Cardioversion Electrical/Chemical Z437 ENT: FB ear removal Z866 Hand: Phalanx w closed reduction F005 Intraarticular MCP# w closed reduction Metacarpal # with close reduction F009 Bennett's # with closed reduction F013 Carpus with close reduction Carpal disl w closd reduction D007 Wrist, Forearm, Elbow: Epicondyle with closed reduction F037 Transcondylar with closed reduction F040 Olecranon with closed reduction Radius & Ulna with closed reduction F024 Radius or Ulna with closed reduction F032 Distal Radius closed redution with GA F046 Disloc elbow D009 Humerus/Shoulder:Tuberosity with closed reduction F048 Humerus neck with closed reduction F054 Humerus neck with head dislocation & closed reduction F051 Humerus shaft with closed reduction F043 Scapula with closed reduction F120 Sternum w closed recution F123 AC with closed reduciton D025 Shoulder disloc with anesthesia D016

Date

Start Time

End Time

Weekend

Holiday

Night (24-7)

Called in?

Emergency?

Emergency

×

A delay in treatment would lead to significant increase in the threat to life or body part (+4 units)

Close

ASA Score ASA 1 ASA 2 ASA 3 (+2 units) ASA 4 (+10 units) ASA 5 (+20 units)

BMI > 40

BMI

×

Close

Prone position

Sitting > 60 degress

Billing Codes

Procedural Sedation note

History

No history or family history of malignant hyperthermia. No problems with previous anesthetics. No history of difficult intubation.

Examination

Normal mouth opening. Normal thryomental distance. Normal mandibular protrusion/able to bite top lip. Normal ROM neck.

Malampati Score Malampati 1 Malampati 2 Malampati 3 Malampati 4

Malampati Score

×

ASA Score

×

Consent

Informed verbal consent was obtained. Risks and benefits were discussed including risk of hypoxia, respiratory arrest, organ damage, parlaysis, brain damage. All questions were answered.

Respiratory therapist was present.

Medications given

Complications

No hypoxia. No desaturation. No assisted ventilation requried.

Discharge Assessment

At the time of discharge was at baseline mental status. Vital signs normal. Able to ambulate safely. Discharged into the care of a responsible adult. Was advised not to drive, operate heavy machinery, use hot tubs, make important decisions, sign legal documents for 24h.

Was provided with written discharge instruction.

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